Many congenital or facial birth defects result in associated deformities of both the internal and external parts of the nose. Often times these are some of the most difficult nose problems to deal with in rhinoplasty surgery. The most common congenital nose deformity is that of cleft lip and palate with the bilateral cleft being the most severe. But many of the other less common craniofacial syndromes have nasal involvement as well, even if there is no direct or obvious connection between the primary craniofacial problem and the nose.
Why congenital craniofacial and facial nose problems are difficult is that there is a basic underdevelopment of the nasal framework (bone and cartilage) or some part of the support structures of the nose is missing. As a result, the overlying nasal skin is often deficient (not expanded) and almost always thick. While nasal frameworks can be rebuilt, it is the quantity and quality of the overlying skin which will ultimately determine the aesthetic outcome of the rhinoplasty procedure.
Accompanying most ‘craniofacial’ noses is an underlying and often significant breathing problem caused by deranged internal anatomy. Significantly deviated septums, underdeveloped middle vaults with internal nasal valve collapse, and nasal tip deformities with external valve obstruction all make for problems with air exchange through the nasal passages. These must be dealt with in almost every such rhinoplasty.
The cornerstone of every congenital rhinoplasty is that cartilage support and reconstruction is needed. Whether this is building up the bridge and dorsal line, providing support for tip reshaping and expansion,, or lengthening the nose with septal struts and spreader grafts, having adequate cartilage to do the job is the key to an optimal outcome. While septum and ear donor sites may often be enough in quantity, their curved shape (ear) and lack of sufficient lengths (septum) are often problematic. For this reason, I often use rib cartilage where volume and lengths are not issues. While it does involve a donor scar and some pain, the volume of cartilage obtained no longer becomes a rate limiting factor for this type of rhinoplasty.
While synthetic materials also offer the same structural benefits as rib cartilage at much less ‘cost’, most congenital rhinoplasties are in younger patients. And while I love synthetic materials in the face for the right application, I have learned that many superficially placed synthetic implants (and the nose is a superficial location being only under skin and not muscle) will often become a problems years to decades later. The nose is simply not a great place for permanent, non-resorbable materials in young patients.
The key to successful use of rib cartilage in congenital rhinoplasty is to place enough that will withstand the recoil of the expanded nasal skin. And the same time, not placing too much under pressure at the tip of the nose that either the blood flow to the tip skin is compromised or the columellar incision is at risk for breakdown.
Dr. Barry Eppley
Indianapolis, Indiana